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    <meta name="author" content="Han Yuping, Zhang Di">
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    <title>测试病人信息登记</title>
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                                <span class="badge pull-right">32</span>
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                        <h1><i class="icon-calendar-empty"></i> 测试病人“王老五”信息登记</h1>
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                        <!-- 吸烟饮酒史-->
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                                <div class="widget-content-white glossed">
                                    <div class="padded">
                                        <h3 class="form-title form-title-first"><i class="icon-calendar"></i>
                                            吸烟饮酒史</h3>

                                        <form action="" role="form" class="form-horizontal">
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">是否每天吸烟?</label>

                                                <div class="col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="wetherSmoking"
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                                                            否
                                                        </label>
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                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="wetherSmoking"
                                                                   value="1">
                                                            是(当前)
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="wetherSmoking"
                                                                   value="2">
                                                            是(过去,已戒烟)
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group" id="noSmokeTime" style="display:none">
                                                <label class="col-md-3 control-label">已经戒烟多久？</label>
                                                <div class="col-md-2">
                                                    <input class="form-control" type="text">
                                                </div>
                                                <div class="col-md-1 left">年</div>
                                                <div class="col-md-2">
                                                    <input class="form-control" type="text">
                                                </div>
                                                <div class="col-md-1 left">月</div>
                                            </div>
                                            <div id="smoke-form" style="display:none">
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">估计一天多少支烟?</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">支</div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">多少岁开始吸烟？</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">岁</div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">吸烟多少年？</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">年</div>
                                                </div>
                                            </div>
                                            <br>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">是否每天饮酒?</label>

                                                <div class="col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherDrink" value="0"
                                                                   checked="checked">
                                                            否
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherDrink" value="1">
                                                            是(当前)
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherDrink" value="2">
                                                            是(过去,已戒酒)
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group" id="noDrinkTime" style="display:none">
                                                <label class="col-md-3 control-label">已经戒酒多久？</label>
                                                <div class="col-md-2">
                                                    <input class="form-control" type="text">
                                                </div>
                                                <div class="col-md-1 left">年</div>
                                                <div class="col-md-2">
                                                    <input class="form-control" type="text">
                                                </div>
                                                <div class="col-md-1 left">月</div>
                                            </div>
                                            <div id="drink-form" style="display:none">
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">估计一天多少两酒?</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">两</div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">酒精度数？</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">度</div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">多少岁开始饮酒？</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">岁</div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">饮酒多少年？</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">年</div>
                                                </div>
                                            </div>

                                            <!--物质滥用-->
                                            <h3 class="form-title form-title-first"><i class="icon-calendar"></i>
                                                物质滥用</h3>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">种类</label>

                                                <div class="col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="0" checked="checked">
                                                            无
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="1">
                                                            海洛因
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="2">
                                                            麻古
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="3">
                                                            冰毒（甲基苯丙胺）
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="4">
                                                            K粉（氯胺酮）
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="5">
                                                            神仙粉（天使粉/苯环己哌啶）
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="6">
                                                            大麻
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="7">
                                                            可卡因
                                                        </label>
                                                    </div>
                                                    <div class="radio col-md-2">
                                                        <label>
                                                            <input type="radio" name="drug"
                                                                   value="8">
                                                            其他：
                                                        </label>
                                                    </div>
                                                    <div class="col-md-2">
                                                        <input type="text" class="form-control">
                                                    </div>
                                                </div>
                                            </div>
                                            <div id="drug-form" style="display:none">
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">开始使用时间：</label>

                                                    <div class="input-group date form_date col-md-3"
                                                         data-date=""
                                                         data-date-format="dd MM yyyy"
                                                         data-link-field="dtp-firsttime"
                                                         data-link-format="yyyy-mm-dd">
                                                        <input class="form-control" size="16" type="text" value=""
                                                               readonly>
                                                        <span class="input-group-addon"><span
                                                                class="glyphicon glyphicon-calendar"></span></span>
                                                    </div>
                                                </div>

                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">频率：</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-2 control-label left">次/月</div>
                                                </div>

                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">最近一次使用距今：</label>

                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">年</div>
                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">月</div>
                                                </div>
                                                <div class="form-group">
                                                    <div class="col-md-offset-3 col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">周</div>
                                                    <div class="col-md-2">
                                                        <input type="number" class="form-control">
                                                    </div>
                                                    <div class="col-md-1 control-label left">天</div>
                                                </div>
                                            </div>

                                            <!-- 婚育、月经史-->
                                            <h3 class="form-title form-title-first"><i class="icon-calendar"></i>
                                                婚育、月经史</h3>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">首次月经时间：</label>

                                                <div class="col-md-2">
                                                    <input type="number" class="form-control">
                                                </div>
                                                <div class="col-md-1 control-label left">岁</div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">月经是否规律：</label>

                                                <div class="col-md-2">
                                                    <div class="radio">
                                                        <label class="control-label">
                                                            <input type="radio" name="menstruation"
                                                                   value="option1" checked="checked">
                                                            是
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label class="control-label">
                                                            <input type="radio" name="menstruation"
                                                                   value="option2">
                                                            否
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="form-group" id="menstrual-cycle">
                                                <label class="col-md-3 control-label">月经周期：</label>

                                                <div class="col-md-2">
                                                    <input type="number" class="form-control">
                                                </div>
                                                <div class="col-md-1 control-label left">天</div>
                                                <div class="col-md-2 control-label">月经持续：</div>
                                                <div class="col-md-2">
                                                    <input type="number" class="form-control">
                                                </div>
                                                <div class="col-md-1 control-label left">天</div>
                                            </div>

                                            <div class="form-group" id="menstrual-reason">
                                                <label class="col-md-3 control-label">请描述：</label>

                                                <div class="col-md-6">
                                                    <input type="text" class="form-control">
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">末次月经时间：</label>

                                                <div id="birthday" class="input-group date form_date col-md-4"
                                                     data-date=""
                                                     data-date-format="dd MM yyyy"
                                                     data-link-field="dtp-firsttime"
                                                     data-link-format="yyyy-mm-dd">
                                                    <input class="form-control" size="16" type="text" value=""
                                                           readonly>
                                                <span class="input-group-addon"><span
                                                        class="glyphicon glyphicon-calendar"></span></span>
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">目前是否怀孕</label>

                                                <div class="col-md-3">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherPregnant"
                                                                   value="0" checked="checked">
                                                            否
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherPregnant"
                                                                   value="1">
                                                            是
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherPregnant"
                                                                   value="2">
                                                            不明
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="whetherPregnant"
                                                                   value="3">
                                                            不适用
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">是否曾经怀孕</label>

                                                <div class="col-md-3">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="oncePregnant"
                                                                   value="0" checked="checked">
                                                            否
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="oncePregnant"
                                                                   value="1">
                                                            是
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="oncePregnant"
                                                                   value="2">
                                                            不适用
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <h5>如果是请回答以下问题:</h5>
                                            </div>
                                            <div class="form-group" id="">
                                                <label class="col-md-3 control-label">总共怀孕次数</label>

                                                <div class="col-md-2">
                                                    <input type="number" class="form-control">
                                                </div>
                                                <div class="col-md-1 control-label left">次</div>
                                                <div class="col-md-2 control-label">活产次数：</div>
                                                <div class="col-md-2">
                                                    <input type="number" class="form-control">
                                                </div>
                                                <div class="col-md-1 control-label left">次</div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3">在怀孕期间及产后一月内，是否曾经有过严重的抑郁：</label>

                                                <div class="col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="depression"
                                                                   value="option1">
                                                            正常
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="depression"
                                                                   value="option2">
                                                            轻度
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="depression"
                                                                   value="option1">
                                                            中度
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="depression"
                                                                   value="option1">
                                                            重度
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3">在怀孕期间及产后一月内，是否曾经有过严重的焦虑：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="anxious"
                                                                   value="0" checked="true">
                                                            正常
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="anxious"
                                                                   value="1">
                                                            轻度
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="anxious"
                                                                   value="2">
                                                            中度
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="anxious"
                                                                   value="3">
                                                            重度
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">育有：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="child"
                                                                   value="1">
                                                            子
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="child"
                                                                   value="0">
                                                            女
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">健康情况：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="child"
                                                                   value="1">
                                                            正常
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="child"
                                                                   value="0">
                                                            异常
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">异常情况描述：</label>

                                                <div class=" col-md-3">
                                                    <input class="form-control" type="text">
                                                </div>
                                            </div>

                                            <!-- 过敏史-->

                                            <h3 class="form-title form-title-first"><i
                                                    class="icon-calendar"></i>
                                                过敏史</h3>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">是否有药物过敏：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drugAllergy"
                                                                   value="0" checked="checked">
                                                            无
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="drugAllergy"
                                                                   value="1">
                                                            有
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div id="drugAllergy-form" style="display:none">
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">何种药物：</label>

                                                    <div class=" col-md-3">
                                                        <input class="form-control" type="text">
                                                    </div>
                                                </div>
                                            </div>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">其他过敏史：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="otherAllergy"
                                                                   value="0" checked="checked">
                                                            无
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="otherAllergy"
                                                                   value="1">
                                                            有
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div id="otherAllergy-form" style="display:none">
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">粉尘：季节性， 特异性</label>

                                                    <div class=" col-md-3">
                                                        <input class="form-control" type="text">
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-3 control-label">食物：水产品或其他</label>

                                                    <div class=" col-md-3">
                                                        <input class="form-control" type="text">
                                                    </div>
                                                </div>
                                            </div>

                                            <h3 class="form-title form-title-first"><i
                                                    class="icon-calendar"></i>
                                                体格检查</h3>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">身高</label>

                                                <div class="col-md-3">
                                                    <input class="form-control col-md-3" type="number">
                                                </div>
                                                <label class="col-md-2 left">米</label>
                                            </div>
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">体重</label>

                                                <div class="col-md-3">
                                                    <input class="form-control col-md-3" type="number">
                                                </div>
                                                <label class="col-md-2 left">公斤</label>
                                            </div>
                                            <div class="form-group">
                                                <label class="col-md-3 control-label">其他</label>

                                                <div class="col-md-3">
                                                    <input class="form-control col-md-3" type="text">
                                                </div>
                                            </div>

                                            <h3 class="form-title form-title-first"><i
                                                    class="icon-calendar"></i>
                                                精神病家族史</h3>

                                            <div class="form-group">
                                                <label class="col-md-3 control-label">是否有精神病家族史：</label>

                                                <div class=" col-md-9">
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="family"
                                                                   value="0" checked="checked">
                                                            无
                                                        </label>
                                                    </div>
                                                    <div class="radio">
                                                        <label>
                                                            <input type="radio" name="family"
                                                                   value="1">
                                                            有
                                                        </label>
                                                    </div>
                                                </div>
                                            </div>
                                            <div id="family-form" style="display:none">
                                                <div class="form-group">
                                                    <img src="../assets/images/area.png" alt="区域图" class="img-rounded">
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-4">上图1级区域里精神障碍的个数</label>

                                                    <div class="col-md-3">
                                                        <input class="form-control col-md-3" type="number">
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-4">上图2级区域里精神障碍的个数</label>

                                                    <div class="col-md-3">
                                                        <input class="form-control col-md-3" type="number">
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-4">上图3级区域里精神障碍的个数</label>

                                                    <div class="col-md-3">
                                                        <input class="form-control col-md-3" type="number">
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <label class="col-md-12">1级区域里2个和/或二级区域里超过3个的请绘制并上传家系图</label>
                                                </div>

                                                <div class="form-group">
                                                    <div class="col-md-offset-3 col-md-4">
                                                        <input class="form-control" type="file">
                                                    </div>
                                                </div>

                                                <!--患有精神疾病史的一级亲属-->
                                                <div class="form-group">
                                                    <label class="col-md-2 control-label">患有精神疾病史的一级亲属</label>

                                                    <div class="col-md-10">
                                                        <a class="btn btn-default btn-sm fdr-addrow"><i
                                                                class="icon-plus-sign"></i>增加一人
                                                        </a>
                                                        &nbsp;
                                                        <a class="btn btn-default btn-sm fdr-delrow"><i
                                                                class="icon-minus-sign"></i>减少一人
                                                        </a>
                                                    </div>
                                                </div>
                                                <div class="form-group">
                                                    <div class="col-md-12">
                                                        <table class="table" id="fdr-table">
                                                            <thead>
                                                            <tr>
                                                                <th>亲属姓名</th>
                                                                <th>精神疾病的名称</th>
                                                                <th>病程（年）</th>
                                                                <th>治疗史</th>
                                                            </tr>
                                                            </thead>
                                                            <tbody>
                                                            <tr class="one-row">
                                                                <td>
                                                                    <input size="16" type="text" class="form-control">
                                                                </td>
                                                                <td>
                                                                    <select class="form-control">
                                                                        <option>(1. 精神分裂症</option>
                                                                        <option>(2. 双相情感障碍</option>
                                                                        <option>(3. 抑郁症</option>
                                                                        <option>(4. 广泛性发育障碍</option>
                                                                        <option>(5. 未确诊的精神障碍</option>
                                                                    </select>
                                                                </td>
                                                                <td>
                                                                    <input class="form-control" type="number"/>
                                                                </td>
                                                                <td>
                                                                    <select class="form-control">
                                                                        <option>(1. 正规治疗，规律服药</option>
                                                                        <option>(2. 正规治疗，间断服药</option>
                                                                        <option>(3. 非正规治疗</option>
                                                                    </select>
                                                                </td>
                                                            </tr>
                                                            </tbody>
                                                        </table>
                                                    </div>
                                                </div>
                                            </div>
                                            <h3 class="section-title">&nbsp;</h3>

                                            <div class="form-group">
                                                <div class="col-md-offset-4 col-md-8">
                                                    <a role="button" class="btn btn-primary btn-lg btn-round"
                                                       href="patient2.html">上一页</a>
                                                    &nbsp;&nbsp;
                                                    <a role="button" class="btn btn-primary btn-lg btn-round"
                                                       href="patient4.html">下一页</a>
                                                </div>
                                            </div>
                                        </form>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
</div>
</body>

<script src="../libs/jquery/1.10.2/jquery.min.js"></script>
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<script>
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